ENT-Focused CT Reporting of the Paranasal Sinuses

Purpose

For an ENT surgeon, sinus CT is not merely a statement that mucosal thickening is present. It is a three-dimensional operative roadmap that should answer five questions: Where is the disease? Which drainage pathway is obstructed? What anatomy is altering access or drainage? What structures make surgery hazardous? Is there a complication or an alternative diagnosis? This framework aligns with published systematic approaches to preoperative CT interpretation.^{[1][2][^3]}

A useful report should therefore describe:

• Disease distribution, laterality, morphology, and severity.
• Patency of each relevant outflow pathway.
• Surgically important anatomic variants, especially those that change the operative corridor.
• High-risk relationships to the orbit, skull base, optic nerves, carotid arteries, and ethmoidal arteries.
• Bone remodeling, osteitis, dehiscence, or destructive change.
• Extrasinus orbital, intracranial, dental, deep facial, or nasopharyngeal abnormalities.

Noncontrast thin-section CT is generally preferred for chronic inflammatory disease and surgical planning because of its excellent bony detail. Isotropic acquisition with multiplanar axial, coronal, and sagittal reconstructions is important; contrast-enhanced CT or MRI is added when tumor, invasive infection, or orbital/intracranial complication is suspected.^{[4][5][^6]}

Reporting priorities

Disease versus anatomy

Separate the report mentally into two layers:

1. Disease map: mucosal thickening, fluid, secretions, polyps, hyperattenuating material, opacification, osteitis, expansion, erosion, and extrasinus extension.
2. Surgical map: ostia and recesses, uncinate processes, turbinates, lamellae, skull-base height, orbital walls, ethmoidal arteries, Onodi cells, sphenoid pneumatization, and carotid/optic canal relationships.

The CT appearance of mucosal disease must be correlated with symptoms and endoscopy. Mild mucosal thickening is common and should not automatically be labeled clinically significant sinusitis; imaging alone neither establishes the full clinical diagnosis of chronic rhinosinusitis nor determines candidacy for surgery.^{[7][8][^9]}

State laterality

ENT planning is side-specific. For every important finding, state right, left, or bilateral, particularly for drainage-pathway obstruction, frontal recess anatomy, skull-base asymmetry, lamina papyracea defects, low-lying anterior ethmoidal arteries, Onodi cells, optic/carotid dehiscence, and septal deviation.

Describe the pattern

Useful morphology includes:

• Mild, moderate, or near-complete mucosal thickening.
• Partial versus complete opacification.
• Air-fluid level or bubbly secretions.
• Polypoid versus smooth circumferential thickening.
• Hyperattenuating or mineralized contents.
• Expansile remodeling versus aggressive permeative destruction.
• Wall sclerosis or thickening suggesting chronic osteitis.
• Unilateral focal disease versus bilateral inflammatory distribution.

The Lund-Mackay score may be included when requested or useful for longitudinal/research standardization: each frontal, maxillary, anterior ethmoid, posterior ethmoid, and sphenoid sinus receives 0 for clear, 1 for partial opacification, or 2 for complete opacification; each ostiomeatal complex receives 0 or 2, producing a maximum score of 24. The score is reproducible but does not fully capture disease volume, clinical severity, osteitis, dangerous anatomy, or a focal obstructing lesion.^{[10][11][^12]}

Universal safety check

A practical preoperative safety review is CLOSE:

CLOSE captures major operative hazards but does not replace a sinus-by-sinus analysis, especially of the frontal drainage pathway, maxillary dental floor, nasal septum, turbinates, and revision anatomy.^[14][18]

Frontal sinuses

What ENT needs

The central question is not simply whether the frontal sinus is opacified. The surgeon needs to know the shape and patency of the frontal sinus drainage pathway, which cells displace it, how narrow the frontal ostium/recess is, and where the pathway lies relative to the skull base, orbit, and anterior ethmoidal artery. Thin sagittal images are particularly useful for understanding the anterior-posterior corridor, while coronal images show the medial-lateral dimension; true understanding requires linked triplanar review.^{[21][22][^23]}

Report the disease

Describe:

• Right, left, or bilateral involvement.
• Mucosal thickening versus complete opacification.
• Air-fluid level or aerated secretions when present.
• Hyperattenuating/inspissated contents.
• Frontal sinus expansion, wall thinning, osteitis, focal dehiscence, or destructive change.
• Involvement of the posterior table, anterior cranial fossa, orbit, or frontal soft tissues.
• Mucocele pattern: complete obstruction with smooth expansile remodeling and thinning/dehiscence.

Frontal sinus disease with posterior-table erosion, epidural or subdural collection, cerebritis, or venous thrombosis is urgent. Frontal/frontoethmoidal infection may also produce superior or superomedial orbital subperiosteal abscess.^{[24][25][^26]}

Report the drainage pathway

State whether the frontal recess and frontal ostium are patent, narrowed, or obstructed, and identify the cause when visible: mucosal disease, polyp, postoperative stenosis, bony cell, tumor, or mucocele. The superior attachment of the uncinate process influences whether frontal drainage is directed into the infundibulum or medial to it.^[27][28]

Use IFAC terminology when the anatomy is relevant to surgery:

Not every small cell needs a catalog in every routine report. Name cells that materially narrow, redirect, mimic the frontal sinus, conceal the true drainage tract, or place the anterior ethmoidal artery at risk. A supraorbital ethmoid cell is especially important because it may be mistaken for the frontal sinus and can suspend the anterior ethmoidal artery below the skull base.^{[1][31][^20]}

Report surgical hazards

• Height and symmetry of the frontal sinus floor and adjacent ethmoid roof.
• Keros type and side-to-side skull-base asymmetry.
• Anterior ethmoidal artery position, particularly a low canal or free mesenteric course.
• Supraorbital ethmoid cell and relationship to the artery.
• Lamina papyracea integrity near the frontal recess.
• Frontal intersinus septal position and frontal septal cell.
• Posterior-table thinning, dehiscence, or intracranial extension.
• Markedly narrow frontal ostium or limited anterior-posterior diameter.

Useful report wording

Illustrative source-supplied examples; adapt to the examination.

Left frontal sinus is completely opacified with obstruction of the frontal recess. A left supra-agger frontal cell extends into the sinus and displaces the frontal drainage pathway posteromedially. No frontal sinus expansion, posterior-table erosion, or intracranial extension.

A right supraorbital ethmoid cell is present, with the anterior ethmoidal artery coursing below the skull base in a short bony mesentery—an operative risk variant.

Ethmoid sinuses

What ENT needs

The ethmoid labyrinth is the central operative corridor. The report should divide disease into anterior and posterior ethmoid compartments, evaluate the basal lamella of the middle turbinate, map the skull base and lamina papyracea, and identify cells that change the frontal, maxillary, orbital, optic, or sphenoid relationships.^{[3][33][^34]}

Report the disease

Describe:

• Anterior versus posterior ethmoid involvement on each side.
• Partial or complete cell opacification.
• Polypoid disease and whether it extends into the nasal cavity.
• Hyperattenuating secretions or mineralization.
• Ethmoid bony partitions: preserved, remodeled, osteitic, or destroyed.
• Lamina papyracea and skull-base integrity.
• Orbital, olfactory-cleft, or intracranial extension.

A unilateral ethmoid/nasal-cavity mass, unilateral olfactory recess opacification, focal hyperostosis, bone destruction, extrasinus extension, or lymphadenopathy should raise concern for neoplasm rather than uncomplicated inflammatory disease and generally merits dedicated contrast-enhanced MRI.^{[35][36][^37]}

Report key landmarks

• Uncinate process: normal, lateralized, medialized, pneumatized, absent, atelectatic, or attached to the lamina papyracea; note whether it compromises the infundibulum or creates orbital risk.
• Ethmoid bulla: size and degree of pneumatization; disease within it; relationship to the lamina papyracea and skull base.
• Basal lamella of the middle turbinate: identifies the transition between anterior and posterior ethmoid cells; note disruption or postoperative removal when relevant.
• Lamina papyracea: intact versus dehiscent, side and level of defect, and any prolapse of orbital fat or medial rectus.
• Ethmoid roof: height, asymmetry, focal defect, and relationship to the cribriform plate.
• Anterior ethmoidal artery: at the skull base versus suspended below it.

The Keros classification measures olfactory-fossa depth from the cribriform plate to the ethmoid roof: type I, 1–3 mm; type II, 4–7 mm; and type III, 8–16 mm. Type III creates a longer, thinner lateral lamella, but the report should also identify the lower side, asymmetry, slope, focal dehiscence, and artery position, because Keros type alone does not describe every skull-base risk.^{[38][39][^40]}

Source limitation: Quick reference asks for the “lower-risk side,” while this detailed section asks for the lower side and asymmetry. Both wordings are retained. “Lower side” and “lower-risk side” should not be treated as interchangeable.

Gera classification can supplement Keros when used locally: class I is an angle greater than 80 degrees, class II 45–80 degrees, and class III less than 45 degrees; a smaller angle indicates a more vertically sloping lateral lamella and greater theoretical injury risk. This is useful but is less universally expected than explicit description of Keros type and asymmetry.^[39][41]

Report variant cells selectively

• Haller/infraorbital ethmoid cell: report if it narrows the maxillary infundibulum, contains disease, or alters the orbital floor/infraorbital canal relationship.^[42][43]
• Supraorbital ethmoid cell: report because it affects frontal drainage orientation and anterior ethmoidal artery position.^[13][20]
• Onodi/sphenoethmoid cell: report side and optic nerve/carotid relationship because it changes the posterior ethmoid-sphenoid boundary and creates optic risk.^[3][17]
• Large agger nasi, supra-agger, or suprabullar cells: report when they redirect or obstruct the frontal pathway.^[29][31]

Useful report wording

Illustrative source-supplied examples; adapt to the examination.

Moderate bilateral anterior and posterior ethmoid mucosal disease. The basal lamellae remain identifiable. Keros type II olfactory fossae with the right ethmoid roof 2 mm lower than the left. No skull-base defect.

Focal left lamina papyracea dehiscence at the anterior ethmoid level with a small amount of orbital fat prolapsing medially; no medial rectus prolapse.

Maxillary sinuses

What ENT needs

The key questions are whether the natural ostium and ethmoid infundibulum are patent, what is producing obstruction, whether disease is rhinogenic or potentially odontogenic, and whether the sinus is normally developed, hypoplastic, atelectatic, expansile, or postoperative.^{[42][44][^45]}

Report the disease

Describe:

• Laterality and degree of mucosal disease.
• Air-fluid level, bubbly secretions, polypoid thickening, or complete opacification.
• Hyperattenuating material, calcification, or suspected fungal ball.
• Chronic wall sclerosis/osteitis.
• Smooth expansion or contraction/atelectasis.
• Focal erosion or aggressive destruction.
• Extension into the orbit, premaxillary tissues, retroantral fat, pterygopalatine fossa, or masticator space.

Unilateral maxillary opacification deserves particular attention. Inspect the teeth, ostiomeatal unit, posterior wall, nasal cavity, and retroantral fat rather than assuming uncomplicated sinusitis.^{[45][35][^36]}

Report the outflow pathway

Assess:

• Natural maxillary ostium.
• Ethmoid infundibulum.
• Hiatus semilunaris/middle meatus.
• Uncinate position and attachment.
• Haller cell narrowing.
• Large concha bullosa or paradoxical middle turbinate narrowing the middle meatus.
• Accessory maxillary ostium, particularly when postoperative recirculation is possible.

A Haller cell should be mentioned when large, diseased, or narrowing the infundibulum; its presence alone does not prove causation. Similarly, concha bullosa and other common variants are primarily surgical landmarks and are poorly correlated with inflammatory disease when considered in isolation.^{[42][7][^46]}

Search for dental disease

The sinus CT should include the maxillary alveolus and teeth. In unilateral or floor-predominant maxillary disease, inspect for:

• Periapical lucency or periodontal bone loss.
• Dehiscence of the sinus floor adjacent to a diseased tooth.
• Oroantral communication or fistula.
• Recent extraction socket.
• Displaced root, implant, graft, or other foreign body.
• Implant protrusion into the sinus.

When the spatial relationship is convincing, use wording such as “findings suspicious for odontogenic maxillary sinusitis; dental/endodontic correlation recommended.” CT can demonstrate the dental focus and sinus-floor relationship, but final etiologic confirmation requires clinical dental assessment.^{[45][47][^48]}

Recognize silent sinus syndrome

Report a small, opacified maxillary sinus with inward bowing of its walls, lateralized/retracted uncinate, infundibular obstruction, and inferior bowing of the orbital floor as chronic maxillary atelectasis or, in the appropriate clinical setting, silent sinus syndrome. Mention increased orbital volume, enophthalmos/hypoglobus anatomy, and whether the condition is primary or follows trauma/surgery.^{[49][50][^51]}

Report surgical hazards

• Maxillary hypoplasia and lateralized uncinate abutting the lamina papyracea.
• Dehiscent infraorbital canal or infraorbital nerve traversing a Haller cell/septum.
• Internal maxillary septa if relevant to antral surgery or dental sinus-lift planning.
• Orbital-floor defect or prior repair material.
• Posterior-wall destruction or retroantral fat invasion, which is a red flag for aggressive disease.

Useful report wording

Illustrative source-supplied examples; adapt to the examination.

Near-complete right maxillary sinus opacification with floor-predominant polypoid mucosal thickening contiguous with periapical disease at tooth 3 and focal sinus-floor dehiscence. Findings are suspicious for odontogenic sinusitis.

Left maxillary sinus volume loss with inward bowing of the walls, lateralized uncinate obstructing the infundibulum, and inferior retraction of the orbital floor, consistent with chronic maxillary atelectasis/silent sinus syndrome in the appropriate clinical setting.

Sphenoid sinuses

What ENT needs

The sphenoid sinus is surrounded by the internal carotid arteries, optic nerves, cavernous sinuses, sella, vidian canals, and V2/foramina rotunda. The report must define the pattern of pneumatization, septation, drainage, and neurovascular canal relationship—especially before sphenoidotomy or transsphenoidal surgery.^{[17][52][^53]}

Report the disease

Describe:

• Right, left, or bilateral involvement.
• Partial or complete opacification.
• Air-fluid level or inspissated secretions.
• Hyperattenuating or calcified contents suggesting fungal ball or chronic proteinaceous material.
• Wall sclerosis/osteitis, expansion, thinning, or destruction.
• Obstruction of the sphenoethmoidal recess.
• Sellar, cavernous sinus, clival, optic canal, orbital apex, or intracranial extension.

Isolated sphenoid opacification should not be dismissed. Evaluate for fungal ball, mucocele, neoplasm, cephalocele/CSF leak, invasive fungal disease, and pituitary/skull-base pathology when the morphology is atypical.^{[17][54][^35]}

Report pneumatization

State conchal, presellar, sellar, or postsellar/extensive pneumatization when surgically relevant. Also identify extension into:

• Anterior clinoid processes.
• Optic struts.
• Greater wings.
• Pterygoid processes/lateral recesses.
• Dorsum sellae or clivus.
• Posterior nasal septum or vomer.

Extensive pneumatization can increase exposure of the carotid artery, optic nerve, vidian canal, and V2. Conchal or poorly pneumatized anatomy may make transsphenoidal access more difficult.^{[52][53][^18]}

Report septa

Describe:

• Main intersphenoid septum position; never assume it is midline.
• Accessory or transverse septa.
• Attachment of any septum to the carotid canal or optic canal.
• Incomplete septa that may be mistaken for the true sellar midline.

This is one of the most actionable items in the report because avulsion of a septum attached to the carotid or optic canal can injure the artery or nerve.^{[17][53][^55]}

Report optic and carotid relationships

On each side state, when present:

• Internal carotid canal protrusion or dehiscence.
• Optic canal protrusion or dehiscence.
• Onodi cell and whether the optic nerve traverses or indents its wall.
• Anterior clinoid pneumatization.
• Intercarotid distance or carotid medialization if markedly narrow or asymmetric.
• Relationship of lateral recess pneumatization to the vidian canal and foramen rotundum/V2.

Report drainage and access

• Patency of each sphenoid ostium and sphenoethmoidal recess.
• Superior turbinate anatomy when it affects localization of the ostium.
• Rostrum, vomer, and posterior septal pneumatization or prior resection.
• Postoperative sphenoidotomy size and restenosis, when applicable.

Useful report wording

Illustrative source-supplied examples; adapt to the examination.

Sellar/postsellar sphenoid pneumatization with bilateral lateral recess extension. The left carotid canal protrudes into the sinus with focal bony dehiscence. An accessory intersphenoid septum inserts onto the left carotid canal.

Left Onodi cell pneumatizes superolateral to the sphenoid sinus, with the left optic canal forming its superolateral wall; no definite canal dehiscence.

Nasal cavity

What ENT needs

The nasal cavity determines surgical access, nasal airflow, topical medication delivery, and endoscopic visualization. The report should describe abnormalities that materially narrow a corridor, displace landmarks, occupy the olfactory cleft, or suggest a unilateral mass.^{[56][57][^58]}

Turbinates

Report:

• Middle turbinate: concha bullosa (lamellar, bulbous, or extensive), paradoxical curvature, lateralization, truncation, duplication, instability, or postoperative resection.
• Inferior turbinate: marked hypertrophy, bony enlargement, mucosal hypertrophy, or asymmetric compensation opposite septal deviation.
• Superior turbinate: major asymmetry, pneumatization, inversion, or lesion affecting the sphenoethmoidal recess/olfactory cleft.

A concha bullosa should be reported when large, asymmetric, diseased, narrowing the middle meatus, displacing the uncinate, or relevant to surgical access. Merely listing a small concha bullosa without explaining its effect is less useful.^{[59][60][^46]}

Meatuses and recesses

State whether there is obstruction of:

• Middle meatus/ostiomeatal unit.
• Superior meatus.
• Sphenoethmoidal recess.
• Olfactory clefts.
• Common nasal meatus when markedly narrowed.
• Choanae and nasopharyngeal airway.

Olfactory-cleft opacification may reflect polyps, respiratory epithelial adenomatoid hamartoma, inflammatory disease, or tumor. Unilateral olfactory recess disease is a red flag and should be evaluated for bone change and often with MRI/endoscopy.^{[61][36][^62]}

Nasal cavity masses

Describe:

• Site of origin or epicenter.
• Unilateral versus bilateral distribution.
• Relationship to septum, turbinates, olfactory cleft, choana, nasolacrimal duct, and sinus ostia.
• Enhancement when contrast is available.
• Focal hyperostosis, remodeling, calcification, erosion, or aggressive destruction.
• Orbital, skull-base, pterygopalatine-fossa, palate, or nasopharyngeal extension.
• Suspicious lymph nodes.

Unilateral nasal obstruction, unilateral bloody discharge, unilateral mass, focal hyperostosis, destructive change, and extrasinus extension require stronger wording than “sinusitis” and usually prompt endoscopic evaluation and contrast-enhanced MRI.^{[35][36][^63]}

Nasolacrimal system

When visible and relevant, report a mass or inflammatory process involving the lacrimal sac, nasolacrimal duct, or inferior meatus. Also identify prior dacryocystorhinostomy anatomy or a lesion that might alter an anterior endonasal approach.

Useful report wording

Illustrative source-supplied examples; adapt to the examination.

Large right bulbous concha bullosa narrows the right middle meatus and displaces the uncinate laterally. Mild compensatory left inferior turbinate hypertrophy.

Unilateral soft-tissue mass centered in the left superior nasal cavity/olfactory cleft with adjacent focal skull-base deossification; recommend ENT endoscopic assessment and contrast-enhanced MRI.

Nasal septum

What ENT needs

For septoplasty or FESS access, “deviated septum” alone is inadequate. State the direction, level, shape, severity, and functional consequence of deviation, including whether a spur contacts a turbinate or blocks the operative corridor.^{[56][57][^58]}

Report systematically

• Direction of the dominant deviation: right or left.
• Anterior cartilaginous, mid-septal, posterior osseous, or multilevel.
• C-shaped, S-shaped, reverse-S, or focal angulation when useful.
• Bony spur: side, level, and contact with inferior or middle turbinate/lateral wall.
• Degree of nasal airway narrowing.
• Effect on the middle meatus, uncinate access, sphenoethmoidal recess, or endoscopic corridor.
• Septal perforation, size and location.
• Septal hematoma/abscess when clinically suspected.
• Septal pneumatization, usually from sphenoid extension, if surgically relevant.
• Postoperative defect, residual deviation, or synechiae.

CT is helpful for middle and posterior deviations and associated sinonasal anatomy, but endoscopy and physical examination remain superior for some anterior septal and internal nasal-valve abnormalities. CT should not be used by itself to determine whether septoplasty is clinically indicated.^[8][64]

Useful report wording

Illustrative source-supplied examples; adapt to the examination.

S-shaped septal deviation, convex right anteriorly and left posteriorly, with a 5-mm leftward osseous spur contacting the left inferior turbinate and narrowing the posterior left nasal passage.

Rightward mid-septal deviation narrows the right middle-meatal surgical corridor but does not obstruct the choana.

Disease patterns ENT needs

Chronic inflammatory disease

State the distribution by sinus and whether it is centered in a drainage pattern:

• Ostiomeatal-unit pattern: maxillary, frontal, and anterior ethmoid disease.
• Sphenoethmoidal-recess pattern: sphenoid and posterior ethmoid disease.
• Diffuse/pansinus disease.
• Sinonasal polyposis, including nasal-cavity and olfactory-cleft involvement.
• Chronic osteitis or neo-osteogenesis.

Describe the actual drainage obstruction rather than relying only on the nonspecific phrase “ostiomeatal complex disease.” The report should help ENT identify the surgical target.^{[2][3][^33]}

Fungal and proteinaceous material

Hyperattenuating sinus contents may reflect inspissated secretions, fungal elements, allergic mucin, or blood. Allergic fungal rhinosinusitis typically produces heterogeneous hyperattenuating contents, often with sinus expansion, smooth remodeling, wall thinning, and sometimes pressure erosion; bone erosion alone does not prove invasive fungal disease.^{[65][66][^67]}

Concern for invasive fungal disease rises with extrasinus fat infiltration, vascular complications, nonenhancing mucosa, orbital apex involvement, perineural spread, or aggressive bone destruction, particularly in an immunocompromised patient. Recommend urgent contrast-enhanced MRI/CT and clinical correlation when those findings are present.^{[68][35][^69]}

Mucocele

Identify the obstructed sinus, smooth expansile remodeling, wall thinning/dehiscence, and displacement of the orbit or intracranial structures. State whether there is superimposed infection or an obstructing mass and identify the likely drainage-point obstruction.

Tumor red flags

Escalate the report when any of the following are present:

• Unilateral nasal cavity or sinus disease without a clear benign explanation.
• Unilateral olfactory-cleft involvement.
• Discrete soft-tissue mass.
• Focal hyperostosis suggesting a possible attachment site.
• Aggressive lytic bone destruction.
• Posterior maxillary-wall or pterygopalatine-fossa involvement.
• Orbital, intracranial, palatal, facial soft-tissue, or nasopharyngeal extension.
• Perineural spread or suspicious nodes.

CT best characterizes bone, while MRI better separates tumor from secretions and defines orbital, intracranial, marrow, and perineural extension.^{[35][36][^37]}

Acute complications

When acute complicated sinusitis is suspected, actively evaluate:

• Preseptal and postseptal cellulitis.
• Medial or superior orbital subperiosteal abscess.
• Orbital abscess, optic nerve compromise, or orbital apex involvement.
• Cavernous sinus thrombosis.
• Epidural or subdural empyema.
• Meningitis, cerebritis, or brain abscess.
• Frontal-bone osteomyelitis/subperiosteal abscess.
• Dural venous sinus thrombosis.

These findings should be placed prominently in the impression and directly communicated when urgent.^{[24][25][^26]}

Revision surgery

Prior surgery removes or distorts landmarks, increasing operative risk. Identify what has actually been performed rather than writing only “postsurgical changes”:^{[2][70][^3]}

• Uncinectomy and maxillary antrostomy: side, size, patency, residual uncinate, and relationship to the natural ostium.
• Anterior/posterior ethmoidectomy and whether basal lamellae remain.
• Middle-turbinate resection, lateralization, or synechiae.
• Frontal sinusotomy and neo-ostium patency/stenosis.
• Sphenoidotomy and ostial patency.
• Septoplasty, turbinate reduction, Draf procedure, or skull-base repair.
• Exposed/dehiscent orbit or skull base.
• Residual cells obstructing drainage, recurrent polyps, osteitis, scar, or mucocele.
• Any new mass or asymmetric destructive process.

Comparison with prior preoperative and postoperative studies is particularly valuable for distinguishing residual anatomy from recurrent disease.

Suggested report structure

Source limitation: the numbered impression sequence below puts urgent findings third; Acute complications and Whole-study safety instead say urgent findings belong prominently or first. Both instructions are retained from the supplied text.

Findings

Frontal sinuses and recesses: Describe disease by side, frontal ostial/recess patency, relevant IFAC cells, posterior table, and frontal surgical anatomy.

Ethmoid sinuses and skull base: Separate anterior/posterior disease; give Keros types and asymmetry; describe lamina papyracea, AEA position, basal lamellae, and relevant Haller/supraorbital/Onodi cells.

Maxillary sinuses and ostiomeatal units: Describe disease, natural ostia/infundibula, uncinate processes, Haller cells, dental sources, volume loss/expansion, and posterior-wall integrity.

Sphenoid sinuses and recesses: Describe disease, ostia, pneumatization, septa, Onodi cells, optic/carotid protrusion or dehiscence, and septal attachments.

Nasal cavity and septum: Describe septal deviation/spurs, turbinates, concha bullosa, meatal narrowing, polyps/masses, olfactory clefts, and choanae.

Orbits, intracranial compartment, and soft tissues: Describe complications, aggressive spread, or state that none is seen when clinically relevant.

Dentition: Mention periapical/periodontal disease and sinus-floor relationship, especially with unilateral maxillary disease.

Impression

Prioritize the impression in this order:

1. Dominant disease pattern and side.
2. Obstructed drainage pathways.
3. Urgent complication, aggressive feature, or alternative diagnosis.
4. Two or three highest-impact operative hazards—not an exhaustive list of innocuous variants.
5. Recommended next imaging or specialist correlation when warranted.

Quick reference

Frontal sinus

• Report frontal ostium/recess patency, not only sinus opacification.
• Name IFAC cells only when they redirect or narrow the drainage pathway.
• Flag a supraorbital cell and low anterior ethmoidal artery.
• Check posterior table, skull base, orbit, mucocele, and intracranial spread.

Ethmoid sinuses

• Separate anterior from posterior disease.
• Report Keros type bilaterally, skull-base asymmetry, and the lower-risk side explicitly.
• Check lamina papyracea for dehiscence and orbital prolapse.
• Identify low AEA, Haller, supraorbital, and Onodi cells when surgically relevant.

Maxillary sinuses

• Report natural ostium, infundibulum, uncinate, and ostiomeatal-unit patency.
• In unilateral/floor-predominant disease, inspect maxillary teeth and sinus floor.
• Flag Haller-cell narrowing, maxillary hypoplasia, accessory ostium, and posterior-wall destruction.
• Recognize chronic maxillary atelectasis/silent sinus syndrome.

Sphenoid sinuses

• Report pneumatization pattern and extensions.
• Identify Onodi cells and optic/carotid protrusion or dehiscence.
• State whether a septum attaches to the carotid or optic canal.
• Do not assume the intersphenoid septum marks midline.

Nasal cavity

• Describe concha bullosa or paradoxical turbinate only when it affects access or drainage.
• Report meatal, sphenoethmoidal-recess, olfactory-cleft, and choanal obstruction.
• Treat unilateral olfactory-cleft disease or a unilateral mass as a red flag.
• Map postoperative turbinate changes and synechiae.

Nasal septum

• State direction, level, shape, severity, and airway/access effect.
• Describe spurs and turbinate contact.
• Report perforation, postoperative defect, or relevant septal pneumatization.
• Remember CT complements—but does not replace—endoscopy and nasal-valve examination.

Whole-study safety

• Apply CLOSE: cribriform plate, lamina papyracea, Onodi cell, sphenoid anatomy, ethmoidal artery.
• Describe drainage pathways, not merely mucosal thickening.
• Escalate unilateral disease, a discrete mass, destructive bone change, extrasinus extension, or complications.
• Put urgent orbital, intracranial, vascular, or invasive-infectious findings first in the impression.